Clinical Indicators: Endoscopic Sinus Surgery, Pediatric

1. History (one or more required)
   (The history must include specific symptoms and findings obtained by the otolaryngologist. A historical diagnosis labeled “sinusitis” by the patient or unsubstantiated symptoms alone is not
   sufficient documentation to establish this as a chronic illness).
   1. Failure of medical management for chronic rhinosinusitis or recurrent acute rhinosinusitis, possibly in addition to other disorders such as one or more of the following:
      1. Allergy
      2. Day care exposure
      3. Gastro-esophageal reflux contributing to rhinosinusitis
      4. Adenoiditis and/or obstructive adenoid hypertrophy
      5. Cystic fibrosis
      6. Immune deficiency disorders
      7. Ciliary dysfunction/dyskinesia
      8. Progressively worsening asthma with opaque sinus(es)
      9. Nasal polyposis with airway obstruction and/or sinusitis
      10. Suspected neoplasm (eg, juvenile nasopharyngeal angiofibroma) (need to get tissue for diagnosis)
      11. Adenoidectomy should be strongly considered a minimum of three months prior to
          performing pediatric sinus surgery for any of the above indications
   2. Intracranial complications
   3. Cavernous sinus thrombosis
   4. Mucocoeles and mucopyocoeles
   5. Subperiosteal or orbital abscess/periorbital cellulitis
   6. Traumatic injury to optic canal (decompression)
   7. Dacryocystitis from rhinosinusitis
   8. Allergic or invasive fungal rhinosinusitis
   9. Meningocephaloceles
   10. Cerebrospinal fluid leaks
   11. Tumors of the nasal cavity, paranasal sinuses, orbit or skull base
   12. Recurrent acute rhinosinusitis (RARS)
2. Physical Examination
   1. Complete anterior and posterior nasal examination (rhinoscopy after mucosal decongestion), as possible for patient’s age—(required)
   2. Nasal endoscopic examination, obtained following medical therapy – (optional)
3. Tests
   1. For surgical planning, coronal CT scan is required in all cases following medical therapy.
   2. Complete axial CT scan… recommended in cases with complex disease.
   3. MRI – optional in cases with suspected intracranial pathology.
   4. Culture and sensitivity-optional
   5. Allergy testing-optional
4. Optimal Medical Therapy: (prior to obtaining sinus CT scan, nasal endoscopy, and surgery)
   1. Evaluation and management for all medical conditions listed
      above.
   2. Treatment of rhinitis medicamentosa, when present.
   3. Parental education of environmental factors including allergens, irritants, or secondhand tobacco smoke.
   4. Antibiotic therapy consisting of four to six consecutive weeks of appropriate antibiotic drugs.
   5. Appropriate topical and/or systemic steroids when indicated.
5. Surgical Procedure and Findings
   1. Must be compatible with clinical status, CT findings, and nasal endoscopic findings that is, only patients with significant persistent sinus symptoms and pathology should undergo
      surgery.
   2. Extensive sinus surgery is rarely indicated in the pediatric age group. Anterior ethmoidectomy and/or maxillary antrostomy may be all that is required.

Postoperative Observations

1. Bleeding, eyelid ecchymosis; notify surgeon
2. Pain- severe headache; notify surgeon
3. Follow-up endoscopy under anesthesia may be indicated for epistaxis, packing removal, or lysis of adhesions
4. Vision- if there is loss of vision or noted to have double vision, notify surgeon immediately
5. Swelling – is there evidence of facial edema? If hematoma, notify surgeon
6. Mental status – is patient alert and oriented? If not, notify surgeon

Associated ICD-10-CM Diagnostic Codes (Representative, but not all-inclusive codes)

• C31.0 Malignant neoplasm of maxillary sinus
• C31.1 Malignant neoplasm of ethmoidal sinus
• C31.2 Malignant neoplasm of frontal sinus
• C31.3 Malignant neoplasm of sphenoid sinus
• D14.0 Benign neoplasm of middle ear, nasal cavity and accessory sinuses
• G96.0 Cerebrospinal fluid leak
• H05.011 Cellulitis of right orbit
• H05.012 Cellulitis of left orbit
• H05.013 Cellulitis of bilateral orbits
• H05.019 Cellulitis of unspecified orbit
• J01.00 Acute maxillary sinusitis, unspecified
• J01.01 Acute recurrent maxillary sinusitis
• J01.10 Acute frontal sinusitis, unspecified
• J01.11 Acute recurrent frontal sinusitis
• J01.20 Acute ethmoidal sinusitis, unspecified
• J01.21 Acute recurrent ethmoidal sinusitis
• J01.30 Acute sphenoidal sinusitis, unspecified
• J01.31 Acute recurrent sphenoidal sinusitis
• J01.40 Acute pansinusitis, unspecified
• J01.41 Acute recurrent pansinusitis
• J01.80 Other acute sinusitis
• J01.81 Other acute recurrent sinusitis
• J01.90 Acute sinusitis, unspecified
• J01.91 Acute recurrent sinusitis, unspecified
• J33.1 Polypoid sinus degeneration
• J33.8 Other polyp of sinus
• J32.0 Chronic maxillary sinusitis
• J32.1 Chronic frontal sinusitis
• J32.2 Chronic ethmoidal sinusitis
• J32.3 Chronic sphenoidal sinusitis
• J32.4 Chronic pansinusitis
• J32.8 Other chronic sinusitis
• J32.9 Chronic sinusitis, unspecified
• J34.0 Abscess, furuncle and carbuncle of nose
• J34.1 Cyst and mucocele of nose and nasal sinus
• J34.9 Unspecified disorder of nose and nasal sinuses
• J34.89 Other specified disorders of nose and nasal sinuses
• R09.81 Nasal congestion
• E05.00 Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm
• E05.01 Thyrotoxicosis with diffuse goiter with thyrotoxic crisis or storm
• H05.231 Hemorrhage of right orbit
• H05.232 Hemorrhage of left orbit
• H05.233 Hemorrhage of bilateral orbit
• H05.239 Hemorrhage of unspecified orbit
• H05.221 Edema of right orbit
• H05.222 Edema of left orbit
• H05.223 Edema of bilateral orbit
• H05.229 Edema of unspecified orbit
• S05.10XA Contusion of eyeball and orbital tissues, unspecified eye
• S05.10XD Contusion of eyeball and orbital tissues, unspecified eye
• S05.10XS Contusion of eyeball and orbital tissues, unspecified eye
• S05.11XA Contusion of eyeball and orbital tissues, right eye
• S05.11XD Contusion of eyeball and orbital tissues, right eye
• S05.11XS Contusion of eyeball and orbital tissues, right eye
• S05.12XA Contusion of eyeball and orbital tissues, left eye
• S05.12XD Contusion of eyeball and orbital tissues, left eye
• S05.12XS Contusion of eyeball and orbital tissues, left eye

Patient Information

Endoscopic sinus surgery is performed through an intranasal approach. The decision regarding the appropriate sinuses for treatment depends on radiographic and endoscopic findings combined with the patient’s clinical status following appropriate medical evaluation and therapy. This surgery is performed only after it has been determined that comprehensive medical management has been unsuccessful. Surgical risks in the pediatric age group include post-operative bleeding, orbital complications (visual impairment), intracranial extension (brain damage or infection), persistent or recurrent nasal obstruction due to failure to manage polyps / allergic inflammation, recurrent nasal or sinus infections, and the possibility of interference with facial growth patterns.

Definitions

1. Acute rhinosinusitis (ARS): ARS is a clinical condition characterized by inflammation of
   the mucosa of the nose and paranasal sinuses with associated sudden onset of symptoms of
   purulent nasal drainage accompanied by nasal obstruction, facial pain/pressure/fullness, or
   both of up to 4 weeks duration.
2. Recurrent acute rhinosinusitis (RARS): RARS is characterized by 4 or more recurrent episodes of ARS with complete clearing of symptoms between episodes over a one year period.
3. Chronic rhinosinusitis (CRS): CRS is a clinical disorder characterized by inflammation of the mucosa of the nose and paranasal sinuses with associated signs and symptoms of 12 week consecutive duration. CRS is characterized by 2 or more symptoms, one of which is nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip), with or without facial pain/pressure and reduction or loss of smell with endoscopic evidence of mucopurulence, edema, and/or polyps and/or CT presence of mucosal thickening or air-fluid levels in the sinuses.
4. Chronic rhinosinusitis with polyposis: CRS with polyposis represents a subgroup of CRS
   patients with endoscopic evidence of unilateral or bilateral polyps in the middle meatus.
5. Functional endoscopic sinus surgery (FESS): FESS is a minimally invasive, mucosalsparing surgical technique utilized to treat medically refractory CRS with or without polyps or recurrent acute rhinosinusitis. Rigid endoscopes are employed to visualize the surgical field to achieve one or more of the following goals: (1) to open the paranasal sinuses to facilitate ventilation and drainage from the paranasal sinuses; (2) to remove polyps and/or osteitic bony fragments to reduce the inflammatory load; (3) to enlarge the sinus ostia to achieve optimal instillation of topical therapies; and (4) to obtain bacterial or fungal cultures and tissue for histopathology.

Important Disclaimer Notice (Updated 8/7/14)

Clinical indicators for otolaryngology serve as a checklist for practitioners and a quality care review tool for clinical departments. The American Academy of Otolaryngology—Head and Neck Surgery, Inc. and Foundation (AAO-HNS/F) Clinical Indicators are intended as suggestions, not rules, and should be modified by users when deemed medically necessary. In no sense do they represent a standard of care. The applicability of an indicator for a procedure must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these clinical indicators will not ensure successful treatment in every situation. The AAO-HNS/F emphasizes that these clinical indicators should not be deemed inclusive of all proper treatment decisions or methods of care, nor exclusive of other treatment decisions or methods of care reasonably directed to obtaining the same results. The AAO-HNS/F is not responsible for treatment decisions or care provided by individual
physicians. Clinical indicators are not intended to and should not be treated as legal, medical, or business advice.

CPT five-digit codes, nomenclature and other data are copyright 2009 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein.

© 2012 American Academy of Otolaryngology-Head and Neck Surgery.